Mothers Perception of the Collective Monitoring on the Child Growth and Development*

Results: From the data analysis, two categories emerged: “The exchange of experiences and the autonomy of the subjects from the health promotion model”, where it was identified that the collective monitoring of child growth and development is a time favoring the approach between professionals and patients by motivating family participation by the emphasis on health promotion actions; and “The ability to recognize the reality and identify the difficulties” that indicated the change in care practice by professionals as a difficult task, but of great importance for health care.


Introduction
In the health care of individuals, it is possible to realize the reproduction of concepts and logic that guide professional practice.They are the result of the rationales that guide health actions, leading to the adoption of a given combination of technologies or ways of working to achieve certain health practices, which characterizes technical-care models of health [1].
The technical-care model is characterized not only by the technologies and techniques used but above all, the logic that guides and organizes.Every model requires an ideology, which is the result of the policy objectives and theories that underpin health practices.In care practice, it is possible to see the coexistence of different care models that coexist in a complementary manner [2].
In the context of health care of children in Brazil, effective changes are noted regarding the incorporation of new principles and guidelines aimed at a more comprehensive, equitable practice and seeking the active participation of the subjects.Thus, through the family health strategy (FHS), these changes are gestated, and fundamental meanings have appeared in reorienting the logic of health services, in a change of perspective of the care/ technical-care model [3].
In recent decades, the child monitoring of growth and development throughout the implementation of the child´s health care policies has as the health care model as a reference based on health promotion, by encouraging the integral care practices, strengthening community and health education as the knowledge necessary for this transformation.However, the effective change to practices addressing these bases is still incipient [4].
Thus, the growth and development monitoring consultation of children still takes place through the traditional assistance: professional-centered, with a focus directed to the change detection and treatment [5].These actions tend to maintain the status quo in the process of relationship between professionals and patients, and in this sense, there is no direct responsibility for the parent´s appropriation of knowledge about the health of their children.Often, such behavior is justified due to high demand for care in primary health care services, the system´s gateway [6].
It is common in childcare practices that the information passed on by nurses during consultations creates doubts in mothers.Thus, is necessary to strengthen the nurse and mother relationship during growth and development, with a view to the empowerment, which will have repercussions on the health care of their children [7].
On the other hand, the FHS works in a territory ascribed perspective, with a defined population for planning and execution of actions.However, the large number of families per team makes a limited actions planning, since the spontaneous demand for the service is still high.
Thus, in this context, the collective monitoring of child growth and development (GD) becomes seen as a practice that involves low-cost technologies and high efficiency, based on the prerogative of health promotion.It arises from the concern on practices still rooted in the technical logic/specialized care, which aims to empower families from the appropriation of skills and knowledge essential to the daily child care in their family space and/or community [8].
This alternative is inserted to strengthening the primary health care (PHC) as to consider the family as the subject of an action in the care of children, having a greater contribution to the development of healthy practices by the population and facilitating popular health education [8][9].
In view of the above, this research intends to highlight if the consultation of child growth and development brings impacts to the empowerment of mothers/caregivers regarding the quality of care provided to their children.Thus, this research will contribute to a critical reflection on the empowerment of the subjects for health care.Propagating studies on this theme is relevant because understanding about the process of health education in the territory where the child lives and his family helps in the implementation of public policies and interventions by professionals.
Given the above, when considering the collective monitoring consultation of child GD an action that directs the practice to a new way to do, based on the popular education process in health and care in an integral perspective, the question is: what is the perception of mothers on the collective monitoring of child growth and development?
Therefore, the objective is to describe the mothers´ perception about the collective monitoring of child growth and development.

Method
This is a descriptive research with a qualitative approach, conducted with mothers who participated in the collective GD in two units of the ESF in a city in northeastern Brazil, from August to September 2014.
The inclusion criteria were: being a mother/caregiver responsible for the care of children who have attended at least one meeting of collective monitoring of children´s GD.The exclusion criteria were stipulated as mothers/caregivers outside the area covered by the family health unit (USF) and those who did not use the SUS as a primary health care service.
The participants in the study were 13 mothers who were addressed at two different times in the two USF, obtaining six and seven participants in each USF.The sample size was defined by the theoretical saturation criterion.The evaluation process is a continuous saturation, being held since the start of data collection always to compare the data obtained with the objectives of the study.The similarities in the information show the speech of subjects, understood their representations regarding the research object [10].
For data collection, the technique of participant observation was used.In this sense, when being part of the GD monitoring, the researcher sought to observe how they were conducted, as well as pay attention to how the participants interact in an attempt to identify the strengths and difficulties facing the care of their children as well as realize the alternatives overcoming listed before the circumstances of the subjects involved.
At the end of the collective consultation, each participant individually in the same space of the meeting had semi-structured interviews, and they were recorded.The audios were transcribed in full on the day of the meeting.
Among the questions that guided the interviews, there was the understanding of the participants on the monitoring of children´s GD, and the collective structuring of such moments.They also were asked about the inclusion and participation of subjects in the group.Finally, it was sought to draw a picture of improvement in the performance of the care given to the child after their participation in collective monitoring.
For the organization and analysis of data was used content analysis proposed by Bardin [11].The operation of the data analysis technique was performed by repeated and exhaustive reading of the empirical material, to identify the units of meaning that were coded and aggregated into thematic categories [11].
The theoretical referential adopted in this study is part of the analysis of content proposed by Bardin, which consists of a set of communication analysis techniques, guided by systematic procedures and objectives for describing the content of the speech, which allow the inference of relative knowledge to the conditions of production/reception of messages [11].
For content analysis, this is divided into stages, namely: 1) Pre-analysis: the researcher performs the "choice of the documents to be submitted for analysis, formulates the hypotheses and the objectives"; 2) Analytical description: the material is subjected to an in-depth study guided by the hypotheses and the theoretical reference.Procedures such as coding, categorization and classification are basic at this stage.Concordant and divergent ideas of ideas are sought; 3) Referential interpretation: reflection, intuition based on empirical materials establish relationships, deepening the connections of ideas.In this phase, the researcher deepens his analysis and arrives at more concrete results of the research [11].
It is emphasized that this study followed the ethical and legal principles governing scientific research involving human beings, keeping the voluntary character of the participants and the anonymity of the parties and it was approved by the ethics committee on research of the unit responsible, under Nº 719,949.The mothers were identified by the letter "M" followed by a sequential number from one to thirteen to preserve the anonymity of the subjects.

Results and Discussion
The mother's participants of this study were between 16 and 36 years old.Most of them had not finished elementary school.Regarding employment, only two had a formal contract and were enjoying the maternity leave; the rest were housewives.Regarding marital status, two were single; four were married, and seven were in a stable relationship.In an analogous population studies, the identified profile was also similar, young mothers, with low schooling, housewives and with stable union/married [7,12].
On the data analysis, two thematic categories emerged: "The exchange of experiences and the autonomy of the subjects from the health promotion model" and "The ability to recognize the reality and identify the difficulties."

The exchange of experiences and the autonomy of the subjects from the health promotion model
Currently, it is possible to establish the existence of certain exhaustion in the biomedical paradigm, since alone it could not answer all the existing demands in today´s society.Also, other alternatives, such as health promotion, have become much more qualified proposals to answer the health challenges of contemporary times.
In the studied reality, even though it is a subtle way, changes in child growth monitoring and development have already begun, although there is a strong link with the traditional medical model.It was noticed that in the two units studied consultations were held alternately individual and collective consultations.This is an alternative adopted by some professionals since there is still a strong connection with patients to the hegemonic model of health, in which the medicalization and complaints are highlighted.
In an attempt to overcome such situations, the collective monitoring of children´s GD aims at encouraging a closer relationship between professionals and patients, a factor that provides incentives for family participation by involving them with information about health care and problems of their child, for the emphasis on health promotion and the interrelation of different knowledge [6,13].This reality is evident in the words that follow: Here is like this, each one asks something, and the other who knows can help.

M4.
In the other GD, the mother said that the child fell out of the cart and stood up unconscious because she did not put the right seat belt... Now I am more careful when I put him in the cart, button up a pillow for him not to fall.

M1.
In the collective, it is good the sharing other mothers, the development of each child...Because there are situations that the other child passed and not mine and I am already more vigilant... and to know what it is, when it happens.

M8.
From the interaction between different individuals in the social spaces can be the development of skills inherent to the care of their child, a factor that works to improve the self-esteem and strengthen the sense of belonging to that environment, since they share the same goal in all that space, health, and well-being of their children [5].Reinforcing this idea, the Ottawa charter, a reference to health promotion points care and reciprocity as fundamental principles, saying that everyone should take care of himself, the other, the community and the environment [14].
The participation of patients and the appreciation of knowledge are factors directly related to the conceptual formulation of health promotion and working in this context is part of what is called a collective monitoring of GD [15].In this sense, the work group who promote health is seen as a means of contributing to the development of autonomy and better-living conditions and health of those involved to contribute to overcoming in the model biomedical practices.
Thus, the process of autonomy of the subjects involved in the child´s collective monitoring can be observed through the following lines:

M13.
I think here each one speaks a little...

I always say, especially if I see that I can help.
However, I do not talk much because I am shy [...] But I do not stop asking questions.

M9.
Through the analysis of the speeches, it can be seen that through the collective GD, participants become subjects of action, because there is a greater openness to the expression of their views on a particular situation.Moreover, it is possible to observe some encouragement in the subject since become part of a group where people of their community talk and exchange of common situations experiences to their children.
However, this does not frequently occur in individual consultations, in which the professional, in the high demand for assistance and queues, only guides on the care of the child.In this type of service, the professional is transfigured as the holder of knowledge, because of his verticalized actions [6].Thus, this behavior tends to promote a smaller stimulus to the emergence of the autonomy of the subjects involved.That subject who uses an unquestioning service, participate effectively and does not contribute to the improvement of their health care.
On the other hand, from the strengthening of individual capabilities, patients become empowered, a characteristic that may favor better health to children [15][16].The autonomy, considered a guiding category of health promotion at work, seeking the extension of the control or domain of individuals and communities on the determinants of their health so that they can exercise the independence process [15][16].
Encouraging the participation of the subjects in the collective needs of these individuals acquire the greater capacity for reflection on the conditions of their life.Besides being part of the problem situation, it is essential that patients become members of the transforming action [5,17].
In this sense, for the child's health have effective actions, it is necessary the effective performance of public policies that give families the increase of their autonomy to foster care.

The ability to recognize the reality and identify the difficulties
For a change process takes effect in care practice, there is a demand for professionals with a strong commitment to do this, since breaking with established knowledge is an arduous task.
From this perspective, it is important to work with the community in the context of health promotion, based on the construction of new nursing knowledge, no less qualified, but guided by the opposite view of the hegemonic model of health.It is necessary to have the notion that it is possible to overcome the focus of attention only complaint/behavior and consider wider issues of individuals who are in a particular context [18].
Thus, there is the need to understand the perception of the care model focused on the promotion of health as something innovative, which aims to overcome the difficulties, having as a priority a broader view of the entire health-disease process and especially the relationships established in care, either between professionals or between professionals and patients.
Even with such a direction, it is clear that the literature indicates the incipient in carrying out activities aimed at promoting health.This factor may be due to the ignorance of the professionals confuse this concept with prevention and health education practices.
Therefore, it is important to work with professionals, for enlargement discussions that favor health promotion to increase effective and universal alternative to improve the quality of life of the population [19].Highlighting the attention to collective practices of monitoring the child´s GD, to be questioned about their participation, the mothers reported: It is good!It is good because we participate, we lie on the mattress and all, not to the other ... They only do that.We just get there...

M10.
In the collective, each one speaks what is going on with your child [...] we participate more...In the individual, they measure themselves; we are just holding the child. M6.
[...] There, are not many questions... Here, the boy has more freedom walking and playing.

M13.
From the analysis of the speeches, it is clear that during the public service there is a closer relationship between patients and professionals who come together to discuss the process of care of children.The establishment of this relationship is of fundamental importance for the nursing consultation to succeed and impact on the care provided to the child [5,20].
While patients feel part of the process through their participation in the collective monitoring of children´s GD, these become child-care mediators and active subjects in the health care.Thus, it is through the inter-relationship and bond established with professional that patients demonstrated satisfaction with the care received [18,21].
In this sense, we have the health promotion measures as a valuable tool in strengthening the individual capacities of patients, who by participating in the actions proposed in the collective monitoring of their children´s GD, become subject able to develop the necessary care that they need.Also, the strengthening of the bond established between patients and professionals approach them to the health services.

Conclusion
It is concluded that from the collective GD, the participants become action subjects, strengthen their autonomy and self-esteem in the healthcare process, because there is a greater openness to the expression of their points of view.There is also a closer relationship between patients and professionals who come together to discuss the process of child care.
We showed that the mothers´ perception about the collective monitoring of children´s GD is directed at health promotion model, as you it is possible to see a greater involvement of the participating subjects in the consultations.Despite the predominance of health promotion model, it is still possible to identify traces of the hegemonic health model and practices.
Thus, it is seen the need to present and promote discussions on the importance of holding of actions that have mainly focused on health promotion to emphasize and enhance the practice in everyday health services.
It is noteworthy that the results of this study should be interpreted to consider some limitations.The study to show only the mothers/caregivers´ view, besides that the results of this study are restricted to a single center, not addressing a larger number of situations.Thus, as future perspectives, other studies are expected to be developed with the other primary health care actors and with other health realities.